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Microbiology and antibiotic therapy of oral and maxillofacial infections
Surgical Clinics
S414 Surgical Management of Odontogenic Tumors Eric Carlson, DMD, MD, Knoxville, TN J. Michael McCoy, DDS, Knoxville, TN Odontogenic tumors represent a fascinating spectrum of benign and malignant tumors whose management occupies a time-honored place in our specialty’s surgical repertoire. The number of recommended surgical techniques is at least as significant as the number of tumors, leading to much confusion as to the best way to treat these tumors. While it is clear that a majority of these tumors are benign, different types of treatment should be offered to patients with curative intent. Benign odontogenic tumors are highly curable entities such that appropriate, first-line surgical therapy must be planned logically and appropriately. This notwithstanding, there is substantial disagreement in the international literature regarding the biologic behavior of these tumors and how best to treat them. An evidence-based approach to the management of these tumors is therefore required to optimize the chance for cure of our patients, while at the same time minimizing the deformity that might occur. In particular, the solid or multicystic ameloblastoma is a locally aggressive slow-growing benign neoplasm that is prone to persistence when treated in a conservative fashion. As such, it is generally recommended that a resection with 1.0 to 1.5 cm linear bony margins be performed at the onset of disease so as to cure such patients. Such treatment is curative, while also allowing for effective reconstruction to be performed on an immediate or delayed basis. It is our belief that similar surgical treatment should also be performed for the odontogenic myxoma and Pindborg tumor. The unicystic ameloblastoma exhibiting exclusively intraluminal tumor, however, may be treated more conservatively with the same likelihood of cure. An enucleation and curettage surgery is generally regarded as conservative, yet appropriate and curative surgery for this subtype of ameloblastoma. A similar approach may be followed for management of the ameloblastic fibroma and ameloblastic fibro-odontoma. The malignant odontogenic tumors, represented by the ameloblastic carcinoma and the clear cell odontogenic carcinomas, require more aggressive cancer surgeries, and are associated with a less favorable prognosis. Long-term postoperative follow-up is generally recommended for all patients with odontogenic tumors so as to ensure effective tumor control.
S415 Microbiology and Antibiotic Therapy of Oral and Maxillofacial Infections Thomas Flynn, DMD, Boston, MA 132
The changing microbiology of odontogenic deep space infections has been a topic of considerable interest in recent years. Improved culturing techniques have helped to identify the synergistic roles that anaerobes and streptococci play in these infections. It appears that the initial colonization of the infected site by oral facultative streptococci provides nutrients and a favorable reduced oxygen environment for later growth of obligate anaerobes, mainly Prevotella and Porphyromonas species, Fusobacteria, and peptostreptococci. Immunocompromised patients may, however, harbor unusual pathogens. The implications of this new understanding of oral microbiology in culturing and antibiotic therapy are discussed. Antibiotic resistance is a growing problem in the head and neck region. The effect of antibiotic therapy on antibiotic resistance within individuals and communities is explored, along with the mechanisms of antibiotic resistance. Strategies for treatment of highly resistant organisms are also described. Recent data on the antibiotic sensitivity of the commonly isolated pathogens of odontogenic infections indicate that penicillin is still the empiric drug of choice, at least for outpatients. The effectiveness of erythromycin and the new macrolides is weak against the oral streptococci and anaerobes, yet concentration of azithromycin into phagocytes may make this macrolide useful. Clindamycin retains its effectiveness in serious (hospitalized) and chronic cases. One can estimate also from these data the usefulness of some newer antibiotics, including new fluoroquinolones and cephalosporins, in odontogenic infections, and that certain older antibiotics are now obsolete. A cost-effectiveness comparison is made among the various available antibiotics and their combinations both by the oral and intravenous routes. Salient pharmacology and antibiotic drug interactions are discussed. References Sakamoto H, Kato H, Sato T, et al: Bull Tokyo Dent Coll 39:103, 1998 Flynn TR: Oral and Maxillofacial Surgery Knowledge Update 2002. Rosemont, IL, American Association of Oral and Maxillofacial Surgeons, 2002 Flynn TR, Halpern LR: Oral Maxillofac Surg Clin North Am 15:17, 2003
S416 Bone Anchored Hearing Aid Application Jonathan E. Burke, DMD, Haddonfield, NJ Guy L. Lanzi, DMD, Haddonfield, NJ Patients who suffer from conductive and mixed loss hearing impairment have previously had limited options for rehabilitation. Those who also suffer from chronic ear canal infections, draining ears, congenital ear malforAAOMS • 2003
S414 Surgical Management of Odontogenic Tumors Eric Carlson, DMD, MD, Knoxville, TN J. Michael McCoy, DDS, Knoxville, TN Odontogenic tumors represent a fascinating spectrum of benign and malignant tumors whose management occupies a time-honored place in our specialty’s surgical repertoire. The number of recommended surgical techniques is at least as significant as the number of tumors, leading to much confusion as to the best way to treat these tumors. While it is clear that a majority of these tumors are benign, different types of treatment should be offered to patients with curative intent. Benign odontogenic tumors are highly curable entities such that appropriate, first-line surgical therapy must be planned logically and appropriately. This notwithstanding, there is substantial disagreement in the international literature regarding the biologic behavior of these tumors and how best to treat them. An evidence-based approach to the management of these tumors is therefore required to optimize the chance for cure of our patients, while at the same time minimizing the deformity that might occur. In particular, the solid or multicystic ameloblastoma is a locally aggressive slow-growing benign neoplasm that is prone to persistence when treated in a conservative fashion. As such, it is generally recommended that a resection with 1.0 to 1.5 cm linear bony margins be performed at the onset of disease so as to cure such patients. Such treatment is curative, while also allowing for effective reconstruction to be performed on an immediate or delayed basis. It is our belief that similar surgical treatment should also be performed for the odontogenic myxoma and Pindborg tumor. The unicystic ameloblastoma exhibiting exclusively intraluminal tumor, however, may be treated more conservatively with the same likelihood of cure. An enucleation and curettage surgery is generally regarded as conservative, yet appropriate and curative surgery for this subtype of ameloblastoma. A similar approach may be followed for management of the ameloblastic fibroma and ameloblastic fibro-odontoma. The malignant odontogenic tumors, represented by the ameloblastic carcinoma and the clear cell odontogenic carcinomas, require more aggressive cancer surgeries, and are associated with a less favorable prognosis. Long-term postoperative follow-up is generally recommended for all patients with odontogenic tumors so as to ensure effective tumor control.
S415 Microbiology and Antibiotic Therapy of Oral and Maxillofacial Infections Thomas Flynn, DMD, Boston, MA 132
The changing microbiology of odontogenic deep space infections has been a topic of considerable interest in recent years. Improved culturing techniques have helped to identify the synergistic roles that anaerobes and streptococci play in these infections. It appears that the initial colonization of the infected site by oral facultative streptococci provides nutrients and a favorable reduced oxygen environment for later growth of obligate anaerobes, mainly Prevotella and Porphyromonas species, Fusobacteria, and peptostreptococci. Immunocompromised patients may, however, harbor unusual pathogens. The implications of this new understanding of oral microbiology in culturing and antibiotic therapy are discussed. Antibiotic resistance is a growing problem in the head and neck region. The effect of antibiotic therapy on antibiotic resistance within individuals and communities is explored, along with the mechanisms of antibiotic resistance. Strategies for treatment of highly resistant organisms are also described. Recent data on the antibiotic sensitivity of the commonly isolated pathogens of odontogenic infections indicate that penicillin is still the empiric drug of choice, at least for outpatients. The effectiveness of erythromycin and the new macrolides is weak against the oral streptococci and anaerobes, yet concentration of azithromycin into phagocytes may make this macrolide useful. Clindamycin retains its effectiveness in serious (hospitalized) and chronic cases. One can estimate also from these data the usefulness of some newer antibiotics, including new fluoroquinolones and cephalosporins, in odontogenic infections, and that certain older antibiotics are now obsolete. A cost-effectiveness comparison is made among the various available antibiotics and their combinations both by the oral and intravenous routes. Salient pharmacology and antibiotic drug interactions are discussed. References Sakamoto H, Kato H, Sato T, et al: Bull Tokyo Dent Coll 39:103, 1998 Flynn TR: Oral and Maxillofacial Surgery Knowledge Update 2002. Rosemont, IL, American Association of Oral and Maxillofacial Surgeons, 2002 Flynn TR, Halpern LR: Oral Maxillofac Surg Clin North Am 15:17, 2003
S416 Bone Anchored Hearing Aid Application Jonathan E. Burke, DMD, Haddonfield, NJ Guy L. Lanzi, DMD, Haddonfield, NJ Patients who suffer from conductive and mixed loss hearing impairment have previously had limited options for rehabilitation. Those who also suffer from chronic ear canal infections, draining ears, congenital ear malforAAOMS • 2003